Transcript slides - Alcohol and Drug Abuse Institute

Relapse Prevention and
Harm Reduction
UW/ABRC
G. Alan Marlatt, Ph.D.
University of Washington
Addictive Behaviors Research Center
http://depts.washington.edu/abrc
(206) 685-1200
Brickman’s Model of Helping & Coping
Applied to Addictive Behaviors
UW/ABRC
Is the person responsible for
changing the addictive behavior?
YES
NO
MORAL MODEL
(War on Drugs)
SPIRITUAL MODEL
(AA & 12-Steps)
Relapse = Mistake, Error, or
Temporary Setback
Relapse = Reactivation of
the Progressive Disease
Is the person YES
Relapse = Crime or Lack of
Relapse = Sin or Loss of
responsible
Willpower
Contact with Higher Power
for the
development
of the
COMPENSATORY MODEL
DISEASE MODEL
addictive
(Cognitive-Behavioral) (Heredity & Physiology)
behavior? NO
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Analysis of High-Risk Situations for Relapse
Alcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and Overeaters
Alcoholics
(N=70)
Smokers
(N=64)
Heroin
Addicts
(N=129)
Gamblers
(N=29)
Overeaters
(N=29)
TOTAL
Sample
(N=311)
Negative Emotional States
38%
37%
19%
47%
33%
35%
Negative Physical States
3%
2%
9%
-
-
3%
Positive Emotional States
-
6%
10%
-
5%
4%
Testing Personal Control
9%
-
2%
16%
-
5%
Urges and Temptations
11%
5%
5%
16%
10%
9%
TOTAL
61%
50%
45%
79%
48%
56%
Interpersonal Conflict
18%
15%
14%
16%
14%
16%
Social Pressure
18%
32%
36%
5%
10%
20%
Positive Emotional States
3%
3%
5%
-
28%
8%
TOTAL
39%
50%
55%
21%
52%
44%
RELAPSE SITUATION
(Risk Factor)
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INTRAPERSONAL DETERMINANTS
INTERPERSONAL DETERMINANTS
“Let’s just go in and see what
happens.”
A Cognitive Behavioral Model of
the Relapse Process
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Effective coping
response
Increased
self-efficacy
Decreased
probability of
relapse
Lapse
Increased
probability of
relapse
High-Risk
Situation
Ineffective
coping response
Decreased
Self-efficacy
¤
Positive outcome
Expectancies
(for initial effects of
the substance)
(initial use of the
substance)
Abstinence
Violation Effect
¤
Perceived effects
of the substance
Relapse Prevention: Specific Intervention Strategies
Self-Monitoring
¤
Inventory of
Drug-Taking Situations
¤
Drug Taking
Confidence
Questionnaire
High-Risk
Situation
Description of
Past Relapses
¤
Relapse Fantasies
Mediation,
Relaxation Training,
Stress Management
¤
Efficacy-Enhancing
Imagery
Ineffective
Coping
Response
Decreased
Self-Efficacy
¤
Positive
Outcome
Expectancies
Situational
Competency Test
¤
Coping-Skill
Training
¤
Contract to limit
extent of use
¤
Reminder Card
(what to do if
you have slip)
Lapse
Education about
immediate vs.
delayed effects
¤
Decision Matrix
Abstinence
Violation Effect
Cognitive
Restructuring
(a lapse is a mistake:
coping vs.
Skill-Training with Alcoholics:
One- Year Follow-Up Results
UW/ABRC
Days of Continuous Drinking
60
SD = 62.2
p < .05
40
20
0
SD = 6.9
Skill training
(Mean = 5.1)
Combined Controls
(Mean = 44.0)
Skill-Training with Alcoholics:
One- Year Follow-Up Results
UW/ABRC
Number of Drinks Consumed
2000
1500
1000
SD = 2218.4
p < .05
SD = 507.8
500
0
Skill training
Combined Controls
(Mean = 399.8)
(Mean = 1592.8)
Skill-Training with Alcoholics:
One- Year Follow-Up Results
UW/ABRC
Days Drunk
80
SD = 17.8
60
p < .05
40
SD = 17.8
20
0
Skill training
(Mean = 11.1)
Combined Controls
(Mean = 64.0)
Skill-Training with Alcoholics:
One- Year Follow-Up Results
UW/ABRC
Controlled Drinking
6
SD = 17.8
P = N.S.
4
SD = 2.6
2
0
Skill training
Combined Controls
(Mean = 4.9)
(Mean = 1.2)
RELAPSE PREVENTION
Empirical Support for the RP Model
UW/ABRC
Narrative Review of 24 Randomized Controlled Trials
Kathleen M. Carroll (1996)
1. While RP usually does not prevent a lapse better than other
active treatments, RP is more effective at “Relapse
Management,” i.e. delaying the first lapse longer and
reducing the duration and intensity of lapses that do occur
before abstinence is regained.
2. RP is particularly effective at maintaining treatment effects
over long-term follow-up measurements of one to two years
or more.
3. RP treatment outcomes often demonstrate “delayed
emergence effects” in which greater improvement in coping
occurs over time.
4. RP may be most effective for “more impaired substance
abusers including those with more severe levels of substance
abuse, greater levels of negative affect, and greater perceived
deficits in coping skills.” (Carroll, 1996, p.52)
RELAPSE PREVENTION
Empirical Support for the RP Model
UW/ABRC
Meta-Analysis Review of 17 Controlled Studies
Irvin, Bowers, Dunn & Wang (1999)
Irvin, Bowers, Dunn, & Wang (1999) selected 17 controlled
studies to evaluate the overall effectiveness of the RP model as
a substance abuse treatment and to statistically identify
moderator variables that may reliably impact the outcome of
RP treatment. In their discussion, they conclude that their
“Results indicate that RP is highly effective for both alcoholuse and substance-use disorders” (p.3)
RELAPSE PREVENTION
Empirical Support for the RP Model
UW/ABRC
Meta-Analysis Review of 17 Controlled Studies
Irvin, Bowers, Dunn, & Wang (1999)
Moderator Variables with Significant Impact on RP Effectiveness
1. Group therapy formats were more effective than individual
therapy formats.
2. RP is more effective as a “stand alone” than as aftercare.
3. Inpatient settings yielded better treatment outcomes than
outpatient settings.
4. Stronger treatment effects on self-reported use than on
physiological measures.
5. While RP was effective across all categories of substance use
disorders, stronger treatment effects were found for
substance abuse than alcohol abuse.
Stages of Change in Substance Abuse &
Dependence: Intervention Strategies
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Maintenance
Stage
Precontemplation
Stage
Contemplation
Stage
Preparation
Stage
Action
Stage
Relapse
Stage
Motivational
Enhancement
Strategies
Assessment
& Treatment
Matching
Relapse
Prevention
& Relapse
Management
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Harm Reduction: History
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 U.K. Model
 Medicalization Approach
 Netherlands
 Normalization Approach
 Junkie bond
Dutch Model
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 Realistic and pragmatic
 Social/health approach
 Openness, “Normalization” leads
to access, control
 Distinction between “soft” and
“hard” drugs
 Low threshold treatment policies
Dutch vs. American Drug Policies
UW/ABRC
 Low vs. High threshold access to
prevention and treatment
programs
 Public health vs. Criminal justice
approach
 Tolerance vs. Zero-tolerance
 Normalization vs.
Denormalization policies
Harm Reduction: Overview
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 Harmful consequences of drug
use can be placed on a continuum
 Goal: to move along this
continuum by taking steps to
reduce harm
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Harm Reduction: Methods
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 Safer route of drug administration
 Alternative, safer substances
 Reduce frequency of drug use
 Reduce intensity of drug use
 Reduce harmful consequences of
drug use
Harm Reduction: Behavior Change
UW/ABRC
 Individual
 Environment
 Policy
Young Heavy Drinkers
UW/ABRC
Heaviest drinking period in life
Problems common, yet more isolated
Development in adulthood?
Problems associated with peer
influence, impulsivity, conduct history
 Do not see drinking as a problem




Spectrum of Intervention Response
Thresholds for Action
No
Problems
Mild
Problems
Moderate
Problems
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Severe
Problems
Treatment
Brief Intervention
Primary Prevention
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UW/ABRC
Alcohol Skills Training Program
Components of Skills Training Program for Secondary Prevention
UW/ABRC





Training in self-monitoring of blood alcohol levels
and drinking moderation techniques
Training to anticipate and prepare for situations
involving increased risk of heavy drinking (e.g. social
pressure, or negative emotional states)
Training to recognize and modify alcohol outcome
expectancies (i.e. placebo vs. drug effects)
Training to alternate stress coping skills (e.g.
relaxation & aerobic exercise)
Training in relapse prevention to enhance
maintenance of drinking behavior change
UW/ABRC
Peak Blood Alcohol Concentration
by Group
UW/ABRC
0.14
0.12
BAC
0.1
0.08
0.06
0.04
0.02
0
Pre
Post
4-month
8-month
12-month
Assessment Interval
Skills Training Program
Alcohol Information
Assessment Control
Project
Brief Alcohol Screening and Intervention for College Students
UW/ABRC
Principal Investigator
Co-Principal Investigator
Co-Principal Investigator
Project Coordinators
Research Coordinator
Research Study Assistant
Graduate Research Assistant
Funding By:
The National Institute of
Alcohol Abuse and
Alcoholism
Grant # 5R37-AA05591
G. Alan Marlatt, Ph.D
John S. Baer, Ph.D.
Daniel R. Kivlahan, Ph.D.
Lori Quigley, Ph.D.
Mary E. Larimer, Ph.D.
Sally Weatherford, Ph.D.
Dan Irvine, BS
Ken Weingardt, MS
Lisa Roberts, MA
Lizza Miller, BA
Jason Kilmer, MS
Linda Dimeff, MS
UW/ABRC
Prevalence of Alcohol-Related Consequences
Among Fraternity and Sorority Members
UW/ABRC
50.0%
47.8%
41.7%
40.0%
39.2%
38.9%
36.8%
36.6%
36.3%
33.7%
29.8%
24.2%
21.9%
16.2%
16.1%
8.1%
7.9%
7.5%
Neglected your responsibilities
Missed a day (or part of a day) of school or work
Not able to do your homework or study for a test
Got into fights, acted bad, or did mean things
Felt you needed more alcohol . . . to get same effect
Caused shame or embarrassment to someone
Had a fight, an argument or bad feelings with a friend
Drove shortly after having more than two drinks
Had blackouts
Noticed a change in your personality
Passed out
Missed out on things . . . spent too much . . . on alcohol
Drove shortly after drinking more than four drinks
Went to work or school high or drunk
Felt that you had a problem with alcohol
Felt physically or psychologically dependent
Felt you were going crazy
Had withdrawal symptoms
BASICS Design
Freshman Year of University
Spring
Quarter
Autumn
Quarter
Select and
assess
high-risk
sample
(random
assignment)
Treatment
No
Treatment
Winter
Quarter
Spring
Quarter
Autumn
UW/ABRC
Quarter
Feedback
And
Advise
Stepped
Care
Options
Stepped
Care
Options
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Screen all
incoming
Freshman
Select and
assess
control
sample
Participant Recruitment






UW/ABRC
4000 Screening Questionnaires mailed
2179 Returned Questionnaires (54%)
2041 Usable Questionnaires interested in participation (51%)
508 High-risk identified (25%)
366 High-risk agreed to participate
- 11 clinical cases
- 7 late responders
- 348 randomized for intervention
174 – High-risk control
174 – High-risk intervention
151 Randomized control group selected
- 115 agreed to participate
(overlap of 26 with high-risk group)
Constructs and Measures
Drinking Measures
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Construct
Measure
Time Frame___
Alcohol
Quantity (6pt)
All points
Consumption
Frequency (7pt)
Peak (6pt)
Alcohol Negative
Consequences
Collateral Report
Daily Drinking Questionnaire
Baseline & FU
Rutgers Alcohol Problem Index (RAPI)
All points
Alcohol Dependence Scale
Baseline& FU
DSM IIIr Dependency Scale (SCID)
Baseline & FU
Quantity, Frequency, & Problems
Baseline & FU
Five General Principles
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 Express Empathy
 Develop Discrepancy
 Avoid Argumentation
 Roll with Resistance
 Support Self-Efficacy
Negotiating a Plan for Change
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 Settings Goals
 Considering Options
 Arriving at a Plan
 Encouraging Action
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Blood Alcohol Concentration*
as a Function of Drinks Consumed
and Time Taken to Consume
UW/ABRC
Number of Drinks
Number of Hours
1
2
3
4
5
6
7
8
9
10
11
12
0
0.020
0.040
0.060
0.080
0.100
0.120
0.140
0.160
0.180
0.200
0.220
0.240
1
0.004
0.024
0.044
0.064
0.084
0.104
0.124
0.144
0.164
0.184
0.204
0.224
2
0.000
0.008
0.028
0.048
0.068
0.088
0.108
0.128
0.148
0.168
0.188
0.208
3
0.000
0.000
0.012
0.032
0.052
0.072
0.092
0.112
0.132
0.152
0.172
0.192
4
0.000
0.000
0.000
0.016
0.036
0.056
0.076
0.096
0.116
0.136
0.156
0.176
5
0.000
0.000
0.000
0.000
0.020
0.040
0.060
0.080
0.100
0.120
0.140
0.160
6
0.000
0.000
0.000
0.000
0.004
0.024
0.044
0.064
0.084
0.104
0.124
0.144
7
0.000
0.000
0.000
0.000
0.000
0.008
0.028
0.048
0.068
0.088
0.108
0.128
8
0.000
0.000
0.000
0.000
0.000
0.000
0.012
0.032
0.052
0.072
0.092
0.112
9
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.016
0.036
0.056
0.076
0.096
10
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.020
0.040
0.060
0.080
* for a MALE, 185 lbs.
Strategies to Reduce
Alcohol Consumption
UW/ABRC
 Keep Track
 Slow Down
 Space Your Drinks
 Select Different Types of Drinks
 Drink for Quality instead of Quantity
 Enjoy Mild Effects
Graphic Feedback
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Frequency of Alcohol Consumption
from High School to College
UW/ABRC
Frequency Scale
3
2.5
2
1.5
1
0.5
0
Spring High School
Random Sample
Autumn College
High Risk Sample
Four Year Outcome Results
UW/ABRC
Drinking Problems
Drinking Problem Z-Score
1.4
1.2
1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
Baseline
Year 1
Year 2
Random Comparison
High-Risk Control
Year 3
Year 4
High-Risk Treatment
Four Year Outcome Results
UW/ABRC
Drinking Rates
Drinking Pattern Z-Score
1
0.8
0.6
0.4
0.2
0
-0.2
Baseline
Year 1
Year 2
Random Comparison
High-Risk Control
Year 3
Year 4
High-Risk Treatment
for Young Heavy Drinkers
 Low Threshold
- Avoids Labels
- Avoids Rules
 Public Health Model
-Treats young people as adults
-Tolerates “illegal” activity
 Flexible
-Tailored to personal history
-Tailored to risk status
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The Three Dangerous Drives in
Adolescent Motivation
Drinking
Dating
Driving
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Thank You.